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/ 2 kb <br /> UNIFIED PROGP-kNI CONSOLIDATED FORbI <br /> UNIDERGROCNDSTOPUGE TANK <br /> OPERATING PERtiIIT APPLICATION-FACILITY INFORtiLATIOY <br /> (ane form per facility) <br /> TOPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7,PERNLANENT FACILITY CLOSURE 400• <br /> Mock one item only) ❑ 3.RENEWAL PERMIT <br /> CjTY <br /> ❑ 6.TE�IPOR4RY FAC[LITYCLOSURE ❑ 9,TRANSFER PER.�G1T <br /> I. FACILITY LNF0RNL4TION <br /> Ti)TAL NUMBER OF UST1 AT FAC Q[TY 'o' FACILTPY ID <br /> 1 <br /> C (Agency Use Only) <br /> F- <br /> EUSINESS/NAME(SaneaPACaMNA.%Eor DEA-Doing 9usiaeaAs) L / <br /> (, T.�l G r'rh fi o L�' rYl TH-y!5 <br /> Gt[ p <br /> BUST S SITE ADDRESS <br /> 1 <br /> 04. <br /> FXILITY TYPE ❑ 1.MOTOR VEHIQ(E FUEL �-0 2.FUEL DISTRIBUTION 4)}' G the facility locatedon Indian Reservation or '�' <br /> 3.FARM 4.PROCESSOR 6.OTHER Tract lends? ❑Yes �No <br /> II. PROPERTY OFVIVER-LNF6RiNLATION <br /> P$OPERTY O WNER NAME 4m. PHONE <br /> 408. <br /> MULING ADDRESS <br /> 366` M.,+ 4, �`. S[�,� ��S 409. <br /> C QY 410. <br /> STATE_ 411. ZIPCODE <br /> RDV E 412. <br /> III. TANK OPERATOR IIYFORMATIOY <br /> TANK OPERATnR N.+ksc <br /> PHONE 421-z <br /> (020 9 q A13-SF 6 a <br /> Nt.tlLING AD KESS _ <br /> A4VV 04. <br /> MY ii -- del . <br /> OGVL�✓x -,2-1-► 1 STATE ZIP CODE sao,� 42$.6 <br /> IY. .TANKOLVNER NFOR1ILATIQN. <br /> TANK OWNER NA.� u. PHONE <br /> tet; P, �. ,!��a �is: <br /> MAILING ADDRESS <br /> a Cf 411 416. <br /> CITY 411. STATE 411. ZIP CODE <br /> O O <br /> .sae .6 419 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/D[STRICT CI 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> S <br /> ❑ 7.FEDERAL AGENCY S.NON-GOVEMIMENT <br /> V. BOARD OF EQUALIZATION US rSTORUGE FEE <br /> ACCOUNT NUMIBER ` <br /> TY(M)HQ 44' 101 01 1 a 1 101Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERtiIIT HOLDER ENFORNMTION <br /> Issue permit and send legal notifications and mailings to: I.FACILITY OWNER 4.TANK OPERATOR 423 <br /> Bl 3.TANK OWNER ❑ 5.FAC&ITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGMA-f VRE <br /> CERTIFICATION: i cer "ghat the informatigarprovided herein is true,accurate,and in full comDU3ace with 1a�a!r uirementl. <br /> APPLICANT SIGN ATL <br /> DATE 424. 3 <br /> APPLICANT NAME M <br /> 426. APPLIC TITLE 4-17 r <br /> UPCF UST-A Rev.(1212007) <br />